Cerebrovascular Complications of COVID-19 on Venovenous Extracorporeal Membrane Oxygenation

Akram M. Zaaqoq; Matthew J. Griffee; Thu Lan Kelly; Jonathon P. Fanning; Silver Heinsar; Jacky Y. Suen; Silvia Mariani; Gianluigi Li Bassi; Jeffrey P. Jacobs; Nicole White; John F. Fraser; Roberto Lorusso; Giles J. Peek; Sung Min Cho

doi:10.1097/CCM.0000000000005861

Cerebrovascular Complications of COVID-19 on Venovenous Extracorporeal Membrane Oxygenation

Akram M. Zaaqoq, Matthew J. Griffee, Thu Lan Kelly, Jonathon P. Fanning, Silver Heinsar, Jacky Y. Suen, Silvia Mariani, Gianluigi Li Bassi, Jeffrey P. Jacobs, Nicole White, John F. Fraser, Roberto Lorusso, Giles J. Peek, Sung Min Cho

School of Medicine

Research output: Contribution to journal › Article › peer-review

Abstract

OBJECTIVES: Evidence of cerebrovascular complications in COVID-19 requiring venovenous extracorporeal membrane oxygenation (ECMO) is limited. Our study aims to characterize the prevalence and risk factors of stroke secondary to COVID-19 in patients on venovenous ECMO. DESIGN: We analyzed prospectively collected observational data, using univariable and multivariable survival modeling to identify risk factors for stroke. Cox proportional hazards and Fine-Gray models were used, with death and discharge treated as competing risks. SETTING: Three hundred eighty institutions in 53 countries in the COVID-19 Critical Care Consortium (COVID Critical) registry. PATIENTS: Adult COVID-19 patients who were supported by venovenous ECMO. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Five hundred ninety-five patients (median age [interquartile range], 51 yr [42-59 yr]; male: 70.8%) had venovenous ECMO support. Forty-three patients (7.2%) suffered strokes, 83.7% of which were hemorrhagic. In multivariable survival analysis, obesity (adjusted hazard ratio [aHR], 2.19; 95% CI, 1.05-4.59) and use of vasopressors before ECMO (aHR, 2.37; 95% CI, 1.08-5.22) were associated with an increased risk of stroke. Forty-eight-hour post-ECMO Paco₂-pre-ECMO Paco₂/pre-ECMO Paco₂(relative ΔPaco₂) of negative 26% and 48-hour post-ECMO Pao₂-pre-ECMO Pao₂/pre-ECMO Pao₂(relative ΔPao₂) of positive 24% at 48 hours of ECMO initiation were observed in stroke patients in comparison to relative ΔPaco₂of negative 17% and relative ΔPao₂of positive 7% in the nonstroke group. Patients with acute stroke had a 79% in-hospital mortality compared with 45% mortality for stroke-free patients. CONCLUSIONS: Our study highlights the association of obesity and pre-ECMO vasopressor use with the development of stroke in COVID-19 patients on venovenous ECMO. Also, the importance of relative decrease in Paco₂and moderate hyperoxia within 48 hours after ECMO initiation were additional risk factors.

Original language	English (US)
Pages (from-to)	1043-1053
Number of pages	11
Journal	Critical care medicine
Volume	51
Issue number	8
DOIs	https://doi.org/10.1097/CCM.0000000000005861
State	Published - Aug 1 2023

Keywords

COVID-19
extracorporeal membrane oxygenation
intracranial hemorrhage
severe acute respiratory syndrome-related coronavirus
stroke
venovenous extracorporeal membrane oxygenation

ASJC Scopus subject areas

Critical Care and Intensive Care Medicine

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10.1097/CCM.0000000000005861

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Zaaqoq, A. M., Griffee, M. J., Kelly, T. L., Fanning, J. P., Heinsar, S., Suen, J. Y., Mariani, S., Li Bassi, G., Jacobs, J. P., White, N., Fraser, J. F., Lorusso, R., Peek, G. J., & Cho, S. M. (2023). Cerebrovascular Complications of COVID-19 on Venovenous Extracorporeal Membrane Oxygenation. Critical care medicine, 51(8), 1043-1053. https://doi.org/10.1097/CCM.0000000000005861

@article{c1d611accfee43c78a12bb9426366216,

title = "Cerebrovascular Complications of COVID-19 on Venovenous Extracorporeal Membrane Oxygenation",

abstract = "OBJECTIVES: Evidence of cerebrovascular complications in COVID-19 requiring venovenous extracorporeal membrane oxygenation (ECMO) is limited. Our study aims to characterize the prevalence and risk factors of stroke secondary to COVID-19 in patients on venovenous ECMO. DESIGN: We analyzed prospectively collected observational data, using univariable and multivariable survival modeling to identify risk factors for stroke. Cox proportional hazards and Fine-Gray models were used, with death and discharge treated as competing risks. SETTING: Three hundred eighty institutions in 53 countries in the COVID-19 Critical Care Consortium (COVID Critical) registry. PATIENTS: Adult COVID-19 patients who were supported by venovenous ECMO. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Five hundred ninety-five patients (median age [interquartile range], 51 yr [42-59 yr]; male: 70.8%) had venovenous ECMO support. Forty-three patients (7.2%) suffered strokes, 83.7% of which were hemorrhagic. In multivariable survival analysis, obesity (adjusted hazard ratio [aHR], 2.19; 95% CI, 1.05-4.59) and use of vasopressors before ECMO (aHR, 2.37; 95% CI, 1.08-5.22) were associated with an increased risk of stroke. Forty-eight-hour post-ECMO Paco2-pre-ECMO Paco2/pre-ECMO Paco2(relative ΔPaco2) of negative 26% and 48-hour post-ECMO Pao2-pre-ECMO Pao2/pre-ECMO Pao2(relative ΔPao2) of positive 24% at 48 hours of ECMO initiation were observed in stroke patients in comparison to relative ΔPaco2of negative 17% and relative ΔPao2of positive 7% in the nonstroke group. Patients with acute stroke had a 79% in-hospital mortality compared with 45% mortality for stroke-free patients. CONCLUSIONS: Our study highlights the association of obesity and pre-ECMO vasopressor use with the development of stroke in COVID-19 patients on venovenous ECMO. Also, the importance of relative decrease in Paco2and moderate hyperoxia within 48 hours after ECMO initiation were additional risk factors.",

keywords = "COVID-19, extracorporeal membrane oxygenation, intracranial hemorrhage, severe acute respiratory syndrome-related coronavirus, stroke, venovenous extracorporeal membrane oxygenation",

author = "Zaaqoq, {Akram M.} and Griffee, {Matthew J.} and Kelly, {Thu Lan} and Fanning, {Jonathon P.} and Silver Heinsar and Suen, {Jacky Y.} and Silvia Mariani and {Li Bassi}, Gianluigi and Jacobs, {Jeffrey P.} and Nicole White and Fraser, {John F.} and Roberto Lorusso and Peek, {Giles J.} and Cho, {Sung Min}",

year = "2023",

month = aug,

day = "1",

doi = "10.1097/CCM.0000000000005861",

language = "English (US)",

volume = "51",

pages = "1043--1053",

journal = "Critical care medicine",

issn = "0090-3493",

publisher = "Lippincott Williams and Wilkins",

number = "8",

}

TY - JOUR

T1 - Cerebrovascular Complications of COVID-19 on Venovenous Extracorporeal Membrane Oxygenation

AU - Zaaqoq, Akram M.

AU - Griffee, Matthew J.

AU - Kelly, Thu Lan

AU - Fanning, Jonathon P.

AU - Heinsar, Silver

AU - Suen, Jacky Y.

AU - Mariani, Silvia

AU - Li Bassi, Gianluigi

AU - Jacobs, Jeffrey P.

AU - White, Nicole

AU - Fraser, John F.

AU - Lorusso, Roberto

AU - Peek, Giles J.

AU - Cho, Sung Min

PY - 2023/8/1

Y1 - 2023/8/1

N2 - OBJECTIVES: Evidence of cerebrovascular complications in COVID-19 requiring venovenous extracorporeal membrane oxygenation (ECMO) is limited. Our study aims to characterize the prevalence and risk factors of stroke secondary to COVID-19 in patients on venovenous ECMO. DESIGN: We analyzed prospectively collected observational data, using univariable and multivariable survival modeling to identify risk factors for stroke. Cox proportional hazards and Fine-Gray models were used, with death and discharge treated as competing risks. SETTING: Three hundred eighty institutions in 53 countries in the COVID-19 Critical Care Consortium (COVID Critical) registry. PATIENTS: Adult COVID-19 patients who were supported by venovenous ECMO. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Five hundred ninety-five patients (median age [interquartile range], 51 yr [42-59 yr]; male: 70.8%) had venovenous ECMO support. Forty-three patients (7.2%) suffered strokes, 83.7% of which were hemorrhagic. In multivariable survival analysis, obesity (adjusted hazard ratio [aHR], 2.19; 95% CI, 1.05-4.59) and use of vasopressors before ECMO (aHR, 2.37; 95% CI, 1.08-5.22) were associated with an increased risk of stroke. Forty-eight-hour post-ECMO Paco2-pre-ECMO Paco2/pre-ECMO Paco2(relative ΔPaco2) of negative 26% and 48-hour post-ECMO Pao2-pre-ECMO Pao2/pre-ECMO Pao2(relative ΔPao2) of positive 24% at 48 hours of ECMO initiation were observed in stroke patients in comparison to relative ΔPaco2of negative 17% and relative ΔPao2of positive 7% in the nonstroke group. Patients with acute stroke had a 79% in-hospital mortality compared with 45% mortality for stroke-free patients. CONCLUSIONS: Our study highlights the association of obesity and pre-ECMO vasopressor use with the development of stroke in COVID-19 patients on venovenous ECMO. Also, the importance of relative decrease in Paco2and moderate hyperoxia within 48 hours after ECMO initiation were additional risk factors.

AB - OBJECTIVES: Evidence of cerebrovascular complications in COVID-19 requiring venovenous extracorporeal membrane oxygenation (ECMO) is limited. Our study aims to characterize the prevalence and risk factors of stroke secondary to COVID-19 in patients on venovenous ECMO. DESIGN: We analyzed prospectively collected observational data, using univariable and multivariable survival modeling to identify risk factors for stroke. Cox proportional hazards and Fine-Gray models were used, with death and discharge treated as competing risks. SETTING: Three hundred eighty institutions in 53 countries in the COVID-19 Critical Care Consortium (COVID Critical) registry. PATIENTS: Adult COVID-19 patients who were supported by venovenous ECMO. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Five hundred ninety-five patients (median age [interquartile range], 51 yr [42-59 yr]; male: 70.8%) had venovenous ECMO support. Forty-three patients (7.2%) suffered strokes, 83.7% of which were hemorrhagic. In multivariable survival analysis, obesity (adjusted hazard ratio [aHR], 2.19; 95% CI, 1.05-4.59) and use of vasopressors before ECMO (aHR, 2.37; 95% CI, 1.08-5.22) were associated with an increased risk of stroke. Forty-eight-hour post-ECMO Paco2-pre-ECMO Paco2/pre-ECMO Paco2(relative ΔPaco2) of negative 26% and 48-hour post-ECMO Pao2-pre-ECMO Pao2/pre-ECMO Pao2(relative ΔPao2) of positive 24% at 48 hours of ECMO initiation were observed in stroke patients in comparison to relative ΔPaco2of negative 17% and relative ΔPao2of positive 7% in the nonstroke group. Patients with acute stroke had a 79% in-hospital mortality compared with 45% mortality for stroke-free patients. CONCLUSIONS: Our study highlights the association of obesity and pre-ECMO vasopressor use with the development of stroke in COVID-19 patients on venovenous ECMO. Also, the importance of relative decrease in Paco2and moderate hyperoxia within 48 hours after ECMO initiation were additional risk factors.

KW - COVID-19

KW - extracorporeal membrane oxygenation

KW - intracranial hemorrhage

KW - severe acute respiratory syndrome-related coronavirus

KW - stroke

KW - venovenous extracorporeal membrane oxygenation

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ER -

Cerebrovascular Complications of COVID-19 on Venovenous Extracorporeal Membrane Oxygenation

Abstract

Keywords

ASJC Scopus subject areas

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